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Summary:

Applicant must possess a high school diploma or equivalent. An associate degree in healthcare administration or finance is preferred. Certification as a Certified Professional Biller (CPB) is required. A minimum of two years of experience in healthcare revenue cycle, medical billing, claims processing, collections, and denial management is required. Experience with Medicare, Medi-Cal, Managed Care, and Commercial Insurance payers is required. Experience in an FQHC, Tribal Health, or community health center is preferred. NextGen experience is preferred.

Must have knowledge of medical terminology, coding concepts, claim adjudication, EOBs, ERAs, payer portals, denial and appeals management, timely filing limits, and appeal processes. Experience with EHR/practice management systems, NextGen, and clearinghouses such as Waystar is preferred. Must understand healthcare regulations, coding standards, and payer requirements related to claim denials and appeals. Must be able to maintain confidentiality and ensure HIPAA compliance while prioritizing workload and consistently meeting productivity goals. Applicant must have a CPR (BLS Provider) certification through the American Heart Association (AHA) or the American Red Cross. Certification may be obtained prior to orientation or within 90 days of employment. The Denials and Appeals Management Clerk is responsible for reviewing, researching, resolving, and appealing denied or underpaid claims to maximize reimbursement and reduce accounts receivable delays. This position works closely with third-party payers, billing, coding, credentialing, providers, and internal departments to ensure timely payment, accurate claim submission, and compliance with applicable regulations. The role also analyzes denial trends, identifies payer issues, supports process improvement, and helps prevent future denials.

This position is eligible for a hybrid work schedule. Must be able to work with the Indian Community and be sensitive to the Indian culture and its needs.

Major Duties and Responsibilities:

Review and prioritize high dollar and timely filing-sensitive denied claims from mail, clearinghouses, payer portals, and work queues. Analyze denied claims, reason codes, and determine appropriate corrective actions. Identify root causes related to coding, insurance eligibility, referral, authorization, provider documentation, or billing errors. Correct claims and resubmit within payer filing limits Monitor aged, denied claims, and maintain denial work queues. Document all actions and follow-up activities in the practice management system. Stay current on changes to payer policies, billing regulations, and reimbursement guidelines. Adhere to patient privacy and confidentiality requirements, including HIPAA regulations. Prepare and submit first-level and second-level appeals as appropriate. Gather supporting medical records, referrals, authorizations, and documentation. Draft appeal letters citing payer policies, medical necessity, coding guidelines, and regulatory requirements. Track appeal status through payer portals, telephone calls, and payer response deadlines until resolution. Escalate unresolved claims to management when appropriate or payer representatives. Coordinate peer-to-peer reviews and reconsideration requests when necessary. Identify denial trends by payer and denial reason and recurring issues. Assist in denial prevention education and implement corrective action plans. Collaborate with coding, billing, patient registration, medical records, and providers to prevent future denials. Maintain denial logs and appeal tracking spreadsheets. Support quality assurance and internal audits. Participate in revenue cycle meetings and payer issue resolution. Monitor denial rates and appeal outcomes. Assist in preparing monthly reports that include denial volume, top denial categories, appeal success rates, timely filing issues, and underpayment trends. This position requires working weekends and evenings, if needed. Other duties assigned relevant to the position, with relevant training and competency assessment documented.

Qualifications Education:

High School Diploma or Equivalent required. Associate degree in healthcare administration, or finance preferred. Certification as a Certified Professional Biller (CPB) is required.

Experience:

A minimum of two years' experience in healthcare revenue cycle, medical billing, claims processing, collections, and denial management is required. Experience with Medicare, Medi-Cal, Managed Care, and Commercial Insurance payers is required. Experience in an FQHC, Tribal Health, or community health center is preferred.

Certification:

CPR (BLS Provider) certification through the American Heart Association (AHA) or the American Red Cross. Certification may be obtained prior to orientation. Certification may obtained within 90 days of employment.

Knowledge of:

Knowledge of medical terminology, CPT, HCPCS, ICD-10-CM Coding concepts, and claim adjudication. Explanation of benefits (EOBs), Electronic Remittance Advice (ERAs), and payer portals. Denial and Appeals Management Clerk. Familiarity with timely filing limits and appeal processes. Proficiency with Electronic Health Records and Practice Management systems (NextGen Preferred). Experience using clearinghouses such as Waystar is preferred. Knowledge of healthcare regulations, coding standards, and payer requirements relevant to claim denials and appeals.

Skill:

Strong analytical, organizational, and problem-solving skills Excellent verbal and written communication skills Microsoft Office applications. Must understand or be willing to receive Native American cultural competency training and employ cultural awareness with our Native American community.

Ability to:

Demonstrated ability to interpret claim denials, review documentation, and develop effective appeal strategies. Proven ability to investigate denials, identify root causes, and implement corrective actions. Ability to prioritize workload and consistently meet productivity goals. Ability to maintain confidentiality and ensure HIPAA compliance. Must be able to work with the Indian Community and be sensitive to the Indian culture and its needs.

Physical Demands:

This position requires prolonged sitting and computer use, occasional lifting of 20 to 25 pounds, and proficiency with computers, keyboards, and standard office equipment. Dexterity of hands with coordination of eye and hand movement.

Remote Work Eligibility:

This position may be eligible for a hybrid work schedule, eligibility is subject to supervisor approval, position requirements, and organizational needs.

Appointment Type:

Full-Time, Non-Exempt Compensation:

$22.00•23.00 per hour ($45,760•47,840 annually, depending on experience and internal equity)

Clinic Location:

San Manuel Indian Health Clinic (11980 Mt. Vernon Ave. Grand Terrance Ca, 92313)

Pay:

$22.00•$23.00 per hour

Benefits:

401(k) Dental insurance Employee assistance program Employee discount Health insurance Life insurance Paid time off Retirement plan Vision insurance

Work Location:

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Denial and Appeals Management Clerk